Knowledge and Skills for Speech-Language Pathologists With Respect to Vocal Tract Visualization and Imaging

ASHA Special Interest Division 3, Working Group on Voice and Voice Disorders

About this Document

This knowledge and skills document is an official statement of the American Speech-Language-Hearing Association (ASHA). This knowledge and skills document was prepared by the ASHA-Special Interest Division 3: Working Group on Voice and Voice Disorders. Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members. ASHA's Legislative Council approved the document as official policy of the Association in March 2003.

The ASHA Scope of Practice (2001) states that the practice of speech-language pathology includes providing services using videoendoscopy/stroboscopy (VES). The Preferred Practice Patterns (ASHA, 1997) are statements that define universally applicable characteristics of practice. It is required that individuals who practice independently in this area hold the Certificate of Clinical Competence in Speech-Language Pathology and abide by the ASHA Code of Ethics, including Principle of Ethics II Rule B, which states: “Individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience” (ASHA, 2003). ASHA Certification in speech-language pathology is necessary, but meeting certification requirements is not sufficient to qualify a person to perform the specific clinical procedure(s) discussed in this document.

Education and training for implementation of VES may be obtained by a variety of means. Some of the training should take place in a clinical setting allowing the speech-language pathologist (SLP) to work with more experienced professionals and a number of patients. The SLPs who intend to perform VES must ensure that they have acquired the knowledge and skills necessary to provide a continuum of service. These knowledge and skill areas form the basis for assessing clinical competency in this specialized area of practice.

The following educational modalities can play an important role in preparing the interested and motivated clinician to perform VES:

Videotape review: Review and interpretation of previously recorded endoscopic examination;

Experience: Experience leading to expertise in performing and interpreting VES in the clinical environment.

Outlined below are the objectives to be met, the recommended proficiencies, and the knowledge and skills recommended to become proficient in the tasks and accomplish each objective.

Objective: To qualify the patient for the procedure.

Proficiency in: Recognition of voice and resonance disorders and identification of patient qualifications for specific procedures.

Knowledge/skills needed:

Understanding of photographic principles of VES and its use as a diagnostic tool.

Knowledge of how to assess patient physiology.

Knowledge of particular patient physiology.

Skills in the performance of VES and clinical interpretation.

Understanding the patient's physical and emotional receptivity to the procedure.

Knowledge of the physiology of voice and resonance production.

Objective: To obtain informed consent for the procedure.

Proficiency in: Discussing all aspects of VES with the patient and/or significant others, as that procedure relates to voice disorders.

Knowledge/skills needed:

Knowledge of VES's role in the context of other objective functional measures of the voice and subjective judgement of voice quality.

Knowledge of vocal-tract anatomy and physiology relative to normal and disordered voice and resonance production.

Knowledge of the advantages and disadvantages of VES.

Knowledge of specific patient safety if topical anesthetic is required, and of the setting and/or circumstances in which administration of a topical anesthetic is appropriate (ASHA, 1992).

Knowledge relative to the significance and interpretation of structure or function deviation to voice and resonance production.

Knowledge of vocal and resonance characteristic interpretation relative to visualization of pathology.

Knowledge of the emotional impact that visual feedback may have on a specific patient.

Objective: To perform the procedure alone or with others.

Proficiency in: Using various tools and procedures that are needed to perform VES.

Knowledge/skills needed:

Knowledge of laryngeal and velopharyngeal anatomy and physiology.

Skill in the technique of rigid fiberoptic oral endoscopy, flexible fiberoptic video nasoendoscopy, or stroboscopic light used to image the vocal tract in a manner that yields maximum quality recordings.

Skill in the techniques of obtaining a videotape of the viewed image.

Knowledge of potential risks to the patient.

Knowledge of various approaches to becoming trained to perform VES.

Knowledge/skill of administration of topical anesthetic to accomplish VES with maximal safety and minimal discomfort to the patient (ASHA, 1992).

Knowledge of universal precaution procedures that protect both clinician and patient from accidental exposure to disease.

Knowledge of the clinical significance of obtained image to make appropriate referrals when necessary.

This requires additional understanding of the visual image dependence on:

Elicited tasks, and

The examiner and patient response to the obtained images.

Knowledge of the ability to organize, store, retrieve VES data for quality assurance and treatment efficacy purposes, and medical-legal documentation.

Objective: To interpret the effects of vocal behavior on the laryngeal anatomy as well as the laryngeal anatomy effects on laryngeal physiology in conjunction with medical colleagues and concisely describe VES findings and interpretations for professional communication purposes.

Proficiency in: Understanding the clinical significance of the image obtained by the VES procedure.

Knowledge/skills needed:

Knowledge of laryngeal physiology.

Knowledge of pathology of the larynx.

Knowledge of the relative effectiveness of therapy, surgery, or medication in the management of specific disorders or diseases of the larynx.

Knowledge of professional communication skills in describing/interpreting VES findings.

Reporting effectively and clearly.

Objective: To interpret the effects of velopharyngeal behavior on resonance as well as the velopharyngeal function effects on voice physiology in conjunction with medical colleagues and concisely describe VES findings and interpretations for professional communication purposes.

Proficiency in: Understanding the clinical significance of the image obtained by the VES procedure.

Knowledge/skills needed:

Knowledge of velopharyngeal physiology.

Knowledge of the impaired function of the velopharynx.

Knowledge of the relative effectiveness of therapy, surgery, or medication in the management of specific disorders involving the velopharynx.

Knowledge of professional communication skills in describing/interpreting VES findings.

Reporting effectively and clearly.

Objective: To design and implement appropriate treatment or response to diagnostic procedure.

Proficiency in: Management of voice and resonance disorders with the use of visual biofeedback from obtained laryngeal and velopharyngeal images.

Knowledge/skills needed:

Skill in the technique of laryngeal and velopharyngeal imaging that provides guided real-time patient visual biofeedback.

Rigid fiberoptic oral endoscopy: (RFOE) is performed with a rigid tube inserted into the oral or pharyngeal cavity. The RFOE has a prism optic system that projects high-intensity light at a predetermined angle illuminating the structures to be observed and recorded. The advantages are high illumination, wide field of view, and excellent image reproduction. The disadvantages are interference with normal speech production and minor patient discomfort.

Flexible fiberoptic nasendoscopy: (FFN) is performed with a flexible nasendoscope inserted through the nasal passage. High-intensity light, transmitted by a fiberoptic bundle, illuminates structures to be viewed by the clinician and/or recorded. The advantages are an excellent image of the vocal folds and velopharyngeal structures during voicing, conversation, or singing, and the potential for image recording and instant replay. The disadvantages are equipment expense and possible patient discomfort.

Stroboscopy: is performed with any of the above instrumentation, when combined with a strobe light correlated to vocal-fold vibration, which permits vocal tract structures to be visualized in an apparent slow motion format. The advantages are an extensive body of information relative to the effect of pathology on the process of voicing, and the potential for providing information about the neuromuscular and physiological integrity of the vocal folds and supraglottic structures. Disadvantages are patient discomfort related to the use of FFN or RFOE and an image restricted to isolated vowel production when the strobe light is used in conjunction with a laryngeal mirror or RFOE.

Reference this material as: American Speech-Language-Hearing Association. (2004). Knowledge and skills for speech-language pathologists with respect to vocal tract visualization and imaging [Knowledge and Skills]. Available from www.asha.org/policy.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

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The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 182,000 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students.